Radiology Coding Alert

Question: An adult patient presented for a two-view chest X-ray. The record noted wheezing, coughing, and trouble catching her breath. The ordering physician documented focal rhonchi and  rdered the X-ray to check for upper respiratory infection (URI). The chest X-ray results revealed acute URI. How should I code this case?

Kansas Subscriber

Answer: For the X-ray, you should report 71020 (Radiologic examination, chest, 2 views, frontal and lateral). Connect 71020 to the appropriate URI ICD-9 code, based on your documentation. If no specific site or sites are documented, you'll need to use nonspecific code 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site).

To further support the chest X-ray, ICD-9 guidelines allow you to report the signs and symptoms as secondary diagnoses. For example, you may report 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) for the rhonchi, which are snore-like sounds caused by the narrowed airway.

The answers for You Be the Coder and Reader Questions were reviewed by Michele Midkiff, CPC-I, PCS, RCC, executive director of Coding Affiliates Inc., an interventional and  neurointerventional radiology coding service in Mountain View, Calif.